1. Sponsored by The Centers for Disease Control and Prevention
Hepatitis B vaccination in prison: The perspective of formerly incarcerated individuals
Jessica M Buck, Kathleen M Morrow, Andrew Margolis, Gloria Eldridge, James Sosman, Diane Binson, Robin MacGowan, Deborah Kacanek, Timothy P Flanigan, and the Project START Study Group
Sponsored by The Centers for Disease Control and Prevention

2. BACKGROUND
Over 6 Million individuals in the US are currently in correctional custody
Over 90% of inmates are eventually released into the community
prison health problems become community health problems

3. 30% of new HBV infections are in people with history of incarceration
HBV antibodies have been detected in up to 50% of inmates at intake
Vaccination of inmates has been recommended by the CDC for the last 20 years, but has not yet been implemented

4. PROJECT START
Project START is a formative study on HIV/STD/hepatitis risk behaviors in young men, 18-29, who are being released from prison
The project is funded by CDC
Conducted in state prisons in California, Mississippi, Rhode Island, and Wisconsin

6. Qualitative assessments provide opportunity to investigate
As part of Project START, this sub-study assesses the feasibility of STD and hepatitis testing and treatment through qualitative and quantitative tools
Qualitative assessments provide opportunity to investigate
knowledge and perceptions of hepatitis
knowledge and attitudes towards HBV vaccine
motivation to be tested/vaccinated for hepatitis
preference of testing/vaccination in prison or in the community

7. STUDY PROCEDURES
Participants were provided $25 to complete a 30-minute qualitative semi-structured interview 6 months after they were released from prison
Interviews focused on STD and hepatitis screening
Interview summaries were content coded and analyzed for emergent themes

8. HBV SCREENING
Participants were offered the opportunity to provide blood and urine samples for STD and hepatitis screening
Serum samples were tested for HBsAG, HBcAB, and HBsAB via ELISA
HBsAB+, HBsAG- : positive - immune
HBsAG+ : positive - chronic carrier/infection
all others : negative - not immune

9. ENROLLMENT AND DEMOGRAPHICS
42 (56%) participants out of 75 eligible men
average age: 24 years
average incarceration time: 3 years
59% African American, 27% Caucasian, 10% Hispanic, and 3% another race
80% single, 17% married, 2% divorced
28 (67%) agreed to be tested for HBV immune responses

10. SEROLOGY RESULTS 71% (20 men) tested HBV negative-not immune
21% (6 men) tested HBV positive-immune
7% (2 men) tested HBV positive-chronic carrier/infection

11. VACCINATION HISTORY Only 10% (4/42 men) had been vaccinated for HBV
2 were vaccinated in prison either by personal request or because of an outbreak in the prison
“They was vaccinating everyone in the prison ‘cause there was a couple of guys in there with it.”

12. “Until this program, I had never heard of it [hepatitis].”
AWARENESS/CONFUSION
52% (22 men) were unaware of or confused about hepatitis, hepatitis testing, and HBV vaccination
“Until this program, I had never heard of it [hepatitis].”
10% (4 men) differentiated between hepatitis B and C
“I don’t know what that is. I don’t know what the difference is between hepatitis B and C.”

13. Less than half showed knowledge about HBV vaccination and vaccination in general
Many did not know whether or not they had been vaccinated
Some confused vaccination with testing, stating they would like to be vaccinated to find out if they had HBV
Some confused vaccination with treatment, stating they would not need to be vaccinated if they did not have HBV

14. “Like I said before, I don’t know nothing about it, but if I thought that it [HBV] was bad, I would [get vaccinated]- as long as it don’t cost too much.”

15. “Man, I have done taken so many shots
“Man, I have done taken so many shots. They say that it is a shot for the flu, it is a shot for this and it is a shot for this - while I was inside and outside and while I was growing up…so I am not sure what they have put in my body.”

16. “I wouldn’t get it [HBV vaccination] cause I ain’t got it [HBV]
“I wouldn’t get it [HBV vaccination] cause I ain’t got it [HBV]. Why would I get the vaccine if I don’t have it?”

17. Some participants were concerned about risk behaviors:
"If I get into a fight with somebody and I break his nose and blood gets on my face, then I'd go for a [HBV] test because you don't know what's in their blood. Say you get it in your eye or something, gets in your tear duct, you know what I mean?”

18. Some were concerned about casual contact in prison
"The fact that I was in prison and around lots of men that were infected…I'm not sure how it's passed and then the boot camp, exposed to the guards throwing other peoples razors all around, and I might have gotten someone else's bar of soap or whatever, toothbrush."

19. WILLINGNESS TO RECEIVE VACCINATION
79% (33 men) said they would be vaccinated.
"Can you get vaccinated to keep from getting that? …Oh, then that is something that I am going to have to look in to, then…Yeah. Do ya'll do that? I might need to check that out.”
Only 1 man said that he would not be vaccinated

20. Most thought that vaccination would be a good precaution to take whether they perceived their risk to be high or low
They were concerned about their own health and the health of their partners, children, and others to whom they could potentially transmit HBV
”[I am worried about HBV because of] Sex and a whole lot of stuff that you might come into contact with it. If you don't know what is going on and you have been vaccinated, then you don't have too much to worry about."

21. HBV VACCINATION BARRIERS
Distrust of prison medical staff was a barrier to vaccination within the prison
“They gave us all kind of shots. I don’t know what they be trying to give. That’s why I don’t be letting them take no shots, I don’t give blood, none of that shit no more. I think they be trying to give me stuff. We in the pen; they don’t care about us when we locked up. You just a body or experiment.”

22. 31% (13 men) mentioned having a fear of needles
Most said that this fear would not prevent them from being vaccinated

23. Time, cost, and inconvenience were barriers to vaccination in the community
"Anything that is going to take money or time would stop me. After [being inside of prison], it's like there ain't a lot of that."

24. STRENGTHS/LIMITATIONS OF THE STUDY
Select group of participants:
18-29 years of age
not incarcerated at time of interview
participants from larger, longitudinal study
long-term relationship may build trust
may not reflect larger population
Multi-site, diversity
black, white, Hispanic, urban and rural

25. SUMMARY OF RESULTS
71% of the men tested were not immune to HBV and could therefore benefit from vaccination
Most of the men interviewed were willing and some even eager to be vaccinated

26. Education of inmates is necessary
differences between hepatitis A, B, and C
purpose of vaccination
HBV vaccination is only against hepatitis B
process of 3 shots at specific times
1-2 shots provides partial immunity

27. CURRENT SITUATION
CDC has recommended HBV vaccination of inmates since 1982
Regulations and programs are currently in place to offer vaccination to children, healthcare workers, and correctional staff, but there are no regulations and few programs for incarcerated adults

28. HBV vaccination is cost-effective:
$8-$25 per dose
approximately $6000 to treat acute infection
much more for chronic infection

29. In a recent survey of 35 state and federal prisons
only 2 routinely vaccinated inmates
9 offered no vaccination at all
Most prison systems have a medical infrastructure already in place and would be willing to implement routine vaccination if funding for the vaccine were available

30. WHY VACCINATE DURING INCARCERATION?
Barriers to testing and vaccination outside prison are often insurmountable
little or no access to healthcare outside correctional system
experience in Project START: none of the men notified that they were not immune to HBV accepted our offer of free vaccination in the community

31. MODEL PROGRAMS OF HBV VACCINATION
Vaccination programs have been shown to be feasible in prisons in France and Spain
A pilot program in the Texas prison system is demonstrating high acceptability of vaccination with a refusal rate (~20%) similar to that of any other medical treatment offered within the system
A pilot program in the women’s prison at the Rhode Island ACI has provided vaccination to 664 women with an acceptance rate of 65%

32. WHAT ARE WE WAITING FOR?

33. Most of all, I’d like to thank our participants.
ACKNOWLEDGEMENTS
Centers for Disease Control and Prevention
Co-Project Officer: Juarlyn Gaitor, PhD (NCHSTP/DHAP/BIRB)
Co-Project Officer: Robin MacGowan, MPH (NCHSTP/DHAP/BIRB)
Co-Project Officer: Richard Wolitski, PhD (NCHSTP/DHAP/BIRB)
California
Principal Investigator: Olga Grinstead, PhD, MPH (University of California, San Francisco, CAPS)
Co-Principal Investigator: Barry Zack, MPH (Centerforce)
Mississippi
Principal Investigator: John Askew, PhD (Jackson State University)
Co-Principal Investigator: Gloria Eldridge, PhD (University of Alaska Anchorage)
Rhode Island
Principal Investigator: Kathleen Morrow, PhD (Brown Medical School/Miriam Hospital)
Co-Principal Investigator: Timothy Flanigan, MD (Brown Medical School/Miriam Hospital)
Wisconsin
Principal Investigator: David Seal, PhD (Medical College of Wisconsin, CAIR)
Co-Principal Investigator: James Sosman, MD (University of Wisconsin Medical School)
Most of all, I’d like to thank our participants.